COMMUNITY SUPPORT SERVICES - INDIVIDUALIZED REHABILITATION PLAN N J Department of Human Services Preliary (60 days) for Provider File Completed (180 days) Send to IME Consumer Name: Robin Smith Date of Birth: 1/1/1960 Gender: Male Female Address: 10 Main St. Scotch Plains NJ 07076 Diagnosis: F20.9 Schizophrenia Consumer Medicaid ID: 123456789 Date of Admission: 3/6/2015 Date of Last Plan: 8/1/2016 Date of New Plan: 2/1/2017 CSS Housing Initiative: SPC 19 GENERIC SPC 20 RIST SPC 21 DDMI SPC 23 MESH SPC 24 FORENSIC SPC 25 ESH SPC 26 RIST/MESH Agency Name: School of Health Professions Agency Address: 1776 Raritan Road Scotch Plains NJ 07076 Phone no.: 732-123-4567 Fax no.: 732-000-0001 Email: shp@sampleirp.com Agency CSS Medicaid ID: 10987654321 SPC 39 AT RISK For Official Use Only: Medicaid: State Funded - State ID:
Directions: For each Rehabilitation Goal, transfer the relevant information from the documents indicated below. First collaborate with the consumer to identify 3-4 knowledge, skill, or resource items listed on IRP Worksheet 1 (KSR). Choose items that are either most important to work on initially, or that the person is most motivated to work on. Then use S-M-A-R-T (Specific, Measureable, Attainable, Realistic, and Timeframe) format to develop measurable objectives related to these areas. : How many times per day / week / or month. E.g., 3X a week. (length of service to be delivered during IRP Term): How many months. E.g. 3 months. Consumer Name: Robin Smith Consumer Medicaid ID: 123456789 Rehabilitation Goal 1 from CRNA: In the next 6 months, I will improve my health by learning how to independently test my blood sugar daily. Valued Life Role: Grandmother Wellness Dimension: Physical Strengths Related to Goal: Robin is motivated to learn how to independently manage her diabetes. She has a glucose monitor and is linked to a primary care physician. KSR Development/Measurable Objective 1: Robin will learn all the steps necessary to test her blood sugar by 3/1/17. Educate Robin about all the functions of her glucose monitor RN 3 Robin s Weekly 30 5 weeks 3 10 residence H2015 HE TD Model the steps of how to test blood sugar RN 3 Robin s Weekly 30 5 weeks 3 10 residence H2015 HE TD KSR Development/Measurable Objective 2: By 2/15/17, Robin will learn at least 1 method to independently track her daily blood sugar level. Model how to use at least 1 tracking system (chart) to monitor BA 4 Robin s Weekly 30 3 weeks 4 6 blood sugar residence KSR Development/Measurable Objective 3: Robin will learn 2 strategies that contribute to a healthy blood sugar level by 8/1/17. Educate Robin about foods that are lower in carbohydrates BA 4 Community Monthly 60 Help Robin explore the pros and cons of adopting a healthier BA 4 Community Bi-weekly 30 lifestyle Educate Robin about exercises she can do at home BA 4 Community Monthly 30 HCPCS Code 6 months 4 24 10 weeks 4 20 6 months 4 12 of Units
Consumer Name: Robin Smith Consumer Medicaid ID: 123456789 Rehabilitation Goal 2 from CRNA: In the next 6 months, I will increase my socialization by attending 2 free events in my community. Valued Life Role: Friend Wellness Dimension: Social Strengths Related to Goal: Robin can use public transportation independently. She is also familiar with her community. KSR Development/Measurable Objective 1: By 8/1/17, Robin will learn 2 healthy coping skills to manage anxious feeling in public settings. Facilitate 2 IMR modules to help Robin identify coping skills to use when she is feeling anxious Peer 5 Community Bi-weekly 60 Review Robin s progress and barriers with practicing coping skills Peer 5 Community Bi-weekly 15 Monitor Robin s ability to use self-management skills and assess symptoms LCSW 3 Community Monthly 30 10 weeks 5 40 10 weeks 5 10 6 months 3 12 H2015 HE HO KSR Development/Measurable Objective 2: For the next 6 months, Robin will identify at least 1 community event each month that she is interested in attending Educate Robin about free events in her area Peer 5 Community Monthly 15 6 months 5 6 KSR Development/Measurable Objective 3: HCPCS Code of Units
Consumer Name: Robin Smith Consumer Medicaid ID: 123456789 BAND + HCPC Code MEDICAID s In each 1. Physician, Psychiatrist (max 8 units daily) 2. Advanced Practice Nurse (max 12 units daily) 3. RN, Psychologist, Licensed Practitioner of the Health Arts, including: Clinical Social Worker, Licensed Rehabilitation Counselor, Licensed Professional Counselor, Licensed Marriage and Family Therapist, Master s Level Community Support Staff 4. Bachelor s Level Community Support Staff, LPN (Individual) 4. Bachelor s Level Community Support Staff, LPN (Group) 5. Associate s Level Community Support Staff, High School Level Community Support Staff, Peer Level Community Support Staff (Individual) 5. Associate s Level Community Support Staff, High School Level Community Support Staff, Peer Level Community Support Staff (Group) Total of Units Preliary (60 days) For Provider file Completed (180 days) Send to IME 1 = H2000 HE 2 = H2000 HE SA 3 = H2015 4 = H0039 5 = H0036 Request for Prior Authorization (PA) Medicaid of units per band of units approved (28 units daily max except 1 & 2) Request for Prior Authorization (PA) State Funded of units per band STATE of units approved (28 units daily max except 1 & 2) IRP Start Date H2015 32 2/1/2017 H0039 62 2/1/2017 H0036 56 2/1/2017 150
SIGNATURES AND CREDENTIALS The development of this Individualized Rehabilitation Plan was a consumer driven process that identifies consumer driven goals. Was the consumer educated and asked to complete a psychiatric advance directive during the development of this plan? Yes. But consumer did not wish to complete a psychiatric directive at this time. Staff will follow up during the next IRP. Yes. But consumer already has a completed psychiatric advance directive. Yes. Staff will work with consumer to develop a psychiatric advance directive. No. Consumer was not educated and asked about a psychiatric advance directive. Robin Smith PRINT OUT & SIGN 2/1/17 Consumer Name Signature Date Lisa Jones, LCSW PRINT OUT & SIGN 2/1/17 Licensed Clinical Staff Team Member Name/s Signature Date Paul Rich, RN PRINT OUT & SIGN 2/1/17 Contributing Team Member Name/s Signature Date Donna Williams, BA PRINT OUT & SIGN 2/1/17 Contributing Team Member Name/s Signature Date Shawn White, CPRP PRINT OUT & SIGN 2/1/17 Optional Signatures: (family members, team member, etc.) Signature Date Optional Signatures: (family members, team member, etc.) Signature Date Please send this form to UBHC IME UM via email at imecss@ubhc.rutgers.edu or fax (732) 235-5569; Call us at (844) 463-2771